11 General introduction Exercise for low back pain The most prevalent musculoskeletal condition is low back pain (LBP) and it affects a substantial proportion of the adult population worldwide (18). LBP leads to significant disability, economic burden, and reduced quality of life (19,20). A key treatment for LBP is exercise therapy, including supervised exercises and HBE, provided by physiotherapists to boost physical function, alleviate pain, facilitate recovery, and enhance selfmanagement (21). HBE consists of targeted exercises prescribed by physiotherapists for home completion to enhance body functions such as joint mobility, muscle strength, or stability (22). Given the benefit of HBE in LBP management and its research interest, it’s surprising that a recent review shows that only 32% of supervised exercise trials for LBP included some form of HBE (23). Moreover, just 45% of these HBE trials reported on patient adherence to the exercise recommendations (23). While there is no existing research specifically examining the consequences of non-adherence to HBE, it is anticipated that these effects might mirror those of non-adherence to medication, potentially leading to substantial economic strain on the healthcare system (24). Regardless of the economic implications, the effectiveness of an exercise intervention is intrinsically linked to the patient’s adherence to the recommended exercise regimen. Adherence to HBE recommendations and its measurement Adherence is usually conceptualized as a behavior and defined as “the extent to which a person’s behavior – taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider” by the World Health Organization (25). Applied to patient adherence to HBE recommendations, adherence would be defined as “the extent to which a person’s behavior corresponds with agreed HBE recommendations from a health care provider”. In this context, the HBE recommendations include frequency (i.e. number of exercise sessions per day or week); intensity (i.e. number of repetitions per exercise session); and quality of performance of the HBE program (how well did the patient perform the exercises compared to the instructions). Despite a clear definition, measuring adherence to HBE recommendations remains a challenge. Various methods for measuring HBE adherence are described in the literature, including diaries, questionnaires, logs, visual scales, tally counters, and single-item questions (23,26–28). However, standardized, valid, and reliable tools to measure adherence are lacking, leading to difficulties in quantifying adherence and understanding its role in treatment outcomes. For instance, to accurately gauge the effectiveness of interventions that include HBE, it is essential to have a reliable method for assessing patients’ adherence to these exercises. Consequently, the development of such a measurement tool is crucial for accurately evaluating the effectiveness of HBEbased interventions, investigating the relationship between adherence to HBE and clinical outcomes , and improving strategies for enhancing adherence in patients with LBP. 1
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